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PUI'. iC HEALTH S�.VX10ES
<br /> SAN JOAQUIN COUNTY
<br /> JOGI KHANNA M.D.,M.P.H. "'• `
<br /> Health Officer
<br /> P.O. Bot 2009 • (1601 Eat Hazelton Avenue) • Stoclaon, Caiifprnia 95201
<br /> (209) 468-3400
<br /> UNDERGROUND TANK DISPOSITION TRACKING RECORD
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<br /> SECTION 1 - Public Health Services Tracking Sheet will accompany each tank affixed with its site identification number. Th
<br /> Tracking Sheet is to be returned to Public Health Services within 30 days of acceptance of the tank by the disposal or recyclit:
<br /> facility. The permit holder is responsible for ensuring that this form is completed and returned.
<br /> FACILITY NAME: G60V T Ii WZO.4 Fi•T/14e/e
<br /> FACILITY ADDRESS:_ le/q, 4!.6 'O 't u- '
<br /> TANK ID #39 - 2 0,�O— c7/ Tank Description: ,5L-
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<br /> SECTION 2 - To be filled out by tank removal contractor:
<br /> Tank Removal Contractor: sE/17G4!2
<br /> Address: 'F3( IrJ lke-Y XWD City: too-eyo Zip: 9535-/
<br /> Phone #: Z09 9653 Date Tank Removed:
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<br /> SECTION 3 - to be filled out by contractor 'decontaminating tank':
<br /> Tank Decontamination Contractor: S'�inGo
<br /> Address: /26pp City: Ra'F-ST0 Zip: 9535/
<br /> Phone #: (Zo$ 1 SZ y< 9G 53
<br /> Authorized representative of contractor certified by signing below that the tank has been decontaminated in an approved
<br /> manner as required by the State Department of Health Services.
<br /> Signature: � j
<br /> Title:_
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<br /> SECTION 4 - To be signed and dated by an authorized representative of the treatment, storage, or disposal facility
<br /> accepting tank and/or piping. ��tJiti "
<br /> Facility Name: /��/lLS t,piQ/00/fj't<ON
<br /> Address: 600 Y-47 S-roeff� City:Z1 Zip: 930/
<br /> Phone #: f{(_/ 236- 06 o.6
<br /> Date Tank Re 'v O 4
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<br /> Signature: Title:/f�{��7 �LtrriL
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<br /> Page 10
<br /> EN 23 049 (Rev 2/8/91) wp
<br /> A Dt tim of Sm jwq—Counry HolCh Cuc SC
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